Veronica Baxter, a MTF transgender inmate who was housed in a male prison in Sydney, hanged herself in her cell back in March 2009. But lest you think the Department of Corrective Services is somehow at fault for having a female prisoner into a male facility, the coroner has decided to clear prison officials of any wrongdoing.

Deputy State Coroner Paul MacMahon said there was nothing to suggest any failure by the department contributed to the death of Veronica Baxter, who was found dead in her cell while on remand at Sydney’s Silverwater Correctional Centre in March 2009. Ms Baxter, formerly known as James Drury, underwent three separate assessments after her arrest on serious drug offences. On each occasion, she was asked about suicidal tendencies but she denied having any such thoughts. One counsellor described her as “smiling, happy and talking”, the coroner said on Monday at the NSW Coroner’s Court at Glebe.

She was held in the cells at the Sydney Police Centre in Surry Hills for five days before being transferred to the Metropolitan Remand and Reception Centre, a male facility at Silverwater. Two days later, the 34-year-old pre-operative transgender male-to-female used a bed sheet to hang herself from a top bunk bed in her cell while awaiting classification.

During a previous incarceration, Baxter actually put in a request to be transferred to a female facility in 2001 before withdrawing it.

On March 10, 2009, three days after Mardi Gras,Veronica Baxter was arrested by Redfern police and held on remand at the all-male NSW Silverwater Metropolitan Reception and Remand Centre. Six days later, after a 14-hour break between checking her cell, she was found dead, hanging in her single cell. Veronica Baxter was an Aboriginal woman from the Cunnamulla country, south-west of Queensland. She dressed, appeared, and had identified as a woman for 15 years and was known by family and friends as a woman. Yet she was placed in an all-male jail. Was Veronica Baxter killed in custody by trans phobic guards or inmates? No-one knows, the only way we will find out is if there is a full, open inquiry.

Ten inmates who were interviewed by a police investigator about Baxter’s mental state indicated that she “appeared to be angry about something [but] there were no indications that suggested that she intended to kill herself”. Baxter had made a number of calls to prison staff using the emergency ‘knock-up box’ in her cell while locked into her cell but no one at the prison could remember who had answered them or what she had wanted.

But don’t worry: Now that she’s dead, prison officials are totally gonna fix their mistakes.

In his one recommendation, MacMahon suggested that, in future, Corrective Services keep records of such calls and who responded to them. He was also concerned that Baxter had apparently been able to hang herself using prison furniture and endorsed suggestions that furniture be further improved to remove hanging points.